National health authorities in Italy have recently required physicians to implement on a large scale the use of telemedicine in their daily care activities; however, no criteria for selecting the type of disorders and/or patients’ characteristics that would indicate the best candidates for telemedicine were provided [6]. In the present study, we found that about one half of the included patients with stable plaque psoriasis on maintenance therapy with biological drugs preferred that their next scheduled visit to the dermatologist be conducted through telemedicine rather than in-person. We investigated this group of patients because their diagnosis is known, their treatment already established and the routine visit usually ends in a confirmation of the therapy in progress. Interestingly, in an earlier study conducted in a primary care setting the preference for telemedicine in a naïve patient population was reported to be only 14% [7]. The analysis of our patients’ characteristics showed that the choice of telemedicine was strongly associated with being younger, being confident with the video-communication tools, having a higher educational level and/or a managerial job and having accessibility to an internet connection at home. These results indicate that a possible negative consequence of a random and large-scale implementation of telemedicine may be inequal access to care within the National Health System to the detriment of those who are older, have a lower level of education and who have either no access to the internet or are not confident with the use of video-communication tools. However, this technology-specific barrier could be overcome through training, changes in management techniques and alternating the delivery of healthcare by telemedicine and personal patient-to-provider interaction [8].

The most reported reasons for preferring telemedicine were saving time, feasibility and safety issues related to the COVID-19 pandemic. It is quite clear that the SARS-Cov-2 pandemic has profoundly influenced the management of in-person care of patients affected by chronic conditions because of the many restrictions for elective and non-urgent visits, particularly during the lockdown [9, 10]. Notably, in response to the COVID-19 pandemic, cancer screening has been suspended, routine diagnostic work deferred and only urgent symptomatic cases prioritized for diagnostic intervention, with a potential for a substantial increase in the number of avoidable cancer deaths in England due to diagnostic delays [11].

Another relevant reason for preferring the in-person visit option was the need of the patient to directly interact with the dermatologist without any technological barriers. Whether the adoption of telemedicine will compromise patient–physician interaction is currently being debated [12]. Although there is currently no evidence that the patient–physician relationship is compromised when telemedicine is used, some authors do believe that telemedicine might impair that relationship [13, 14]. Conversely, others have reported that telemedicine, even in an oncological setting, is perceived as a safe and effective option and that it does not compromise medical care or the patient–physician relationship [15]. A systematic review of the barriers associated with telemedicine identified 33 different issues in the 30 articles in the review, including technically challenged staff, resistance to change, cost, reimbursement, age of patient, educational level of patient and written and verbal communication impairment [16, 17].

Another aspect that needs to be discussed is which dermatological disorders are good candidates to be followed in telemedicine. In our opinion, the best candidates are patients with established chronic skin disorders, such as psoriasis, acne, rosacea and eczema, while other conditions requiring a thorough total body skin examination or special device, such as dermoscopy, are less likely candidates for telemedicine [18]. Interestingly, teledermatology is preferred by the younger patient population with more benign skin conditions, compared to those with neoplastic processes and severe diseases that are more prone for in-person visits to the dermatologist [19]. As early as 2012, teledematology was found to be a promising and reliable tool for the long-term management of patients with psoriasis on systemic treatment (e.g. biologics), and also recommended by those patients who tried it [20, 21]. The effectiveness in assessing the severity of psoriasis was even evaluated in a randomized controlled trial in 296 patients, with the results demonstrating that telemedicine was as effective as the in-person visit [22]. Telemedicine could provide a cost-effectiveness service with an important saving of money by patients [18]. A study on store and forward teledermatology demonstrated that it saves patients from US$ 33.23 to US$ 230.35 per visit [23].

Although in our study included very few patients who expressed their concern for data protection, a secure network for the transmission and storage of confidential patient data and images is essential, and data should be protected to safeguard patient privacy [24]. Another issue to be considered is to what extent the telemedicine could allow the dermatologist to accurately monitor the safety of the treatment with biologicals.

The study is burdened by a number of limitations. First, the questionnaire used was not validated. Nevertheless, the purpose of the designed descriptive questionnaire was exploratory, with the aim to investigate the propensity of patients to choose telemedicine compared to in-person visit. Another limitation is the small sample size, with the patients restricted to those attending two medical centers. It is plausible that the results could be generalized to other Italian areas, but not to other European and extra-European cultures. Finally, we could not address whether the long-term follow-up of the same patient with telemedicine is possible. Further studies are needed to investigate these issues.